IDPH has cited and fined Amberwood Care Centre nursing home in Rockford after a resident there suffered a significant pressure ulcer from a surgical boot.
Bed sores are also referred to sometimes as pressure ulcers or pressure sores because one of the main ingredients in producing them is pressure. The main places that you tend to see pressure ulcers develop is on the bony prominences such as the hips, buttocks, tailbone, and heels. However, pressure from lying on bed or sitting in a chair or wheelchair is not the only way that a nursing home home resident might develop a bed sore or pressure ulcer. Sometimes pressure ulcers can develop due to the use a medical devices such as braces which are intended to immobilize the body part – which is what happened here.
This resident was admitted to the nursing home for rehabilitation after suffering a fractured ankle and having surgery. At the time of her admission, there was a soft cast which was being used to immobilize to allow the fracture site to heal.
When the resident went in for her first follow up appointment, the doctor removed the soft cast and ordered use of a walking boot. The purpose of the walking boot is to allow for some weight bearing while still protecting the fracture site. After the healing process has begun, subjecting the fracture to mild pressure actually helps stimulate bone growth and accelerates the timeline for recovery. However, use of the walking boot is not without risk as pressure from the boot or rubbing against the skin can cause a skin breakdown.
To combat against the risk of skin breakdown, the boot should be removed at least daily to check the skin for signs of skin breakdown. If there are early skins of injury to skin such as redness, pain, or poor capillary refill (a sign of injury to the small blood vessels that supply the skin), then the nurse must notify the doctor so that he can issue orders to prevent further injury or make modifications to the boot so that the skin breakdown doesn’t worsen.
When the resident returned from the doctor’s office with the walking boot, the only wound which was present was the surgical incision which was on the outer aspect of the ankle. The problem arose when the staff did not remove the walking boot or inspect the skin or dressing to the surgical wound for an entire week. The facility wound care nurse came in a week later, removed the boot and saw that the resident had developed a wound on the outside of her foot where there was exposed tendon. Ultimately, the resident had undergo surgical debridement of the pressure sore on her foot and have a wound vac placed in order to attempt to heal the wound caused by either pressure or rubbing from the surgical boot.
This is the kind of outcome which was utterly avoidable. Residents who are at risk for skin breakdown should undergo daily skin inspections as a matter of course – and this was clearly a resident who was at risk for skin breakdowns as the presence of a medical device such as a walking boot is something which is a well-recognized as a risk factor for the development of skin breakdowns.
The more interesting question is why this resident went a whole week without any of the nurses or aides charged with caring for her doing a skin check when it was clearly needed. One answer may be poor training of the staff, but an equally likely explanation is a breakdown in the care planning process. The care plan drives the routine daily care which is provided to residents in a nursing home and must be periodically revised in light of changes in the resident’s condition. The presence of a new medical device probably should have triggered a change in the pressure sore prevention care plan to include daily skin checks, but apparently this never happened and a serious and preventable injury was the result.
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